Colorectal Surgery

Koch pouch operation

Information for patients
What is a Koch pouch operation?
Your consultant has discussed with you an operation called a
Koch pouch. The Koch pouch is also known as a “Continent
Ileostomy”. This operation was first introduced in 1969 and
was largely superseded by the ileo-anal pouch. It is a very rare
operation in the UK, but started being performed again in
2007 at the Oxford Radcliffe Hospitals NHS Trust due to patient
demand. It is used in patients with Ulcerative Colitis or Familial
Adeno Polyposis who have had the colon, rectum and anus
removed.
In this operation the small intestine is connected to an internal
S shaped pouch (reservoir) made out of a piece of small intestine.
A one-way valve, also constructed from the small intestine, is
attached to the reservoir to prevent the flow of waste to the
outside. The pouch is emptied by inserting a special catheter
through the valve approx 2-4 times per day once everything has
settled down (which can take a few weeks) . This removes the
need to wear a bag to deal with the faecal waste. A stoma cap
or gauze square is worn over the stoma.
This operation usually involves a 10-14 days’ stay in hospital.

Fig 1 – Koch pouch

Stoma

Abdominal
Wall
Pouch

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Fig 2 – Continent ileostomy

Fig 3 – Shows suitable appliance

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Who is suitable for this operation?
• Patients who are unsuitable for an ileal-anal pouch procedure
(perhaps they have had a proctectomy so have no anal
opening) or have poor anal tone (poor sphincter control).
• For patients in whom the ileal-anal pouch has failed.
• For those patients who are unhappy with a conventional
spouted permanent end ileostomy.
Before your operation you will be thoroughly assessed by the
colorectal surgeon and stoma care nurse to make sure that this
operation is the best option for you.
A Koch pouch is not suitable for everyone! It is strongly
recommended that you have a consultation with your stoma
care nurse specialist at the colorectal (surgeon) outpatient
appointment. Alternatively, you can arrange to see a stoma care
nurse in the Oxford stoma clinic for a consultation to determine
whether it would be “right” for you, considering your lifestyle
and health.
Contact numbers:
John Radcliffe Hospital site (Oxford): 01865 221839
Churchill Hospital site (Oxford): 01865 235367
Our team of nurse specialists in stoma care is spread across two
major hospital sites in Oxford.

What are the possible risks of this operation?

• Pouchitis – an inflammation of the pouch which results in
fever, abdominal pain, bloating and a need to empty the
pouch more frequently. Pouchitis would be treated with a
course of antibiotics.
• Slippage of valve sometimes occurs in the first 3 months after
the operation. This usually requires an operation to correct it.

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• Fistula.
• Intestinal obstruction.
• Valve stenosis (narrowing).
• Dilated valve resulting in incontinence.
There is also the risk of other complications associated with
major surgery such as deep vein thrombosis, pulmonary
embolism, wound infection, wound leaks.

What does the operation involve?

Preparation for surgery:
The day before surgery it is likely that you will be advised to drink
“clear fluids” (water/ squash/ Bovril drinks/ clear soups etc. –
nothing with “bits” in it). This will help to prepare your bowel.
If you have already had your colon (large bowel) removed, you
will not require any extra “bowel preparation” (laxative). You
will be required to be nil-by-mouth (nothing to eat or drink) for
4 hours before surgery. You will be having a general anaesthetic
for this operation.
Day of surgery:
Most people come in for the operation at a specified time on
the day of surgery. You will have already been to the “Pre-
assessment clinic” approximately 1-3 weeks before the operation
to make sure that you have had blood samples taken and fully
understand what will happen during your stay in hospital.
You will be in the operating theatre for several hours. You will
then go to the recovery room and then to the ward to recover
from the operation. It is likely that you will be very tired after the
operation, so the nursing staff will monitor you closely and make
sure that any pain is controlled.

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After your operation
When you return from the operating theatre there will be a
Medena catheter in the pouch to keep it draining. This will be
stitched in place. Care must be taken to make sure that the
catheter is not dislodged.
The nurses will regularly check your stoma and gauze dressing
and make sure that the catheter is draining correctly. This
catheter will need to stay in place for approximately 14 days after
the operation.
You will also have a “drip” (intravenous fluids) and a separate
catheter (urinary catheter) which drains off the urine from your
bladder. You may also have several wound drains. The urinary
catheter and wound drains are usually removed on the ward
approximately 5 days after the operation.
The day after surgery, the nurses will help you to get out of bed
for a short period in order for your bedding to be changed and
to see to your hygiene needs. You will feel very tired. You will
also see a physiotherapist, who will give you guidance on moving
about and also encourage you to do some breathing exercises to
help clear your lungs after the anaesthetic.
The nurses will be monitoring your blood pressure, pulse and
temperature regularly. They will also be checking your wound
and ensuring that the Medena catheter into the pouch is well
secured and draining freely. They will start to flush this pouch
catheter with some saline (salt water) twice a day to keep it
draining. This is usually started approximately two days after the
operation. After about five days, warm tap water can be used
for the flush rather than saline. During the week, your stoma
care nurse will visit you most days making sure that everything is
satisfactory with the Medena catheter.
When you are feeling well enough, the nursing staff will teach
you how to flush the catheter yourself. This involves a syringe

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with a nozzle and 20ml saline or warm tap water. It is very easy
to do.
By the time you are discharged you must be able to do this
yourself twice a day. You will be given plenty of time to master
the technique.
Approximately 2-4 weeks after the operation you will be taught
how to catheterise the Koch pouch with a Medena catheter
about 4-8 times a day. After the pouch has settled (which
takes several weeks), it only needs to catheterised approximately
2-4 times a day.
Fig 4 – Koch pouch with Medena catheter in situ

Medena
Catheter

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Eating and drinking
While you are in hospital you will gradually resume eating and
drinking. Immediately after the operation you will start to drink
sips of water and as your body settles down you will be allowed
to eat a light diet.
The dietician will visit you on the ward and advise you on eating
and drinking. You will need to chew your food very thoroughly
as the waste will need to come through the Medena catheter.
It is wise to avoid fibre, as this may block the catheter. It is a
good idea to drink grape or prune juice (approximately 210ml
daily) to keep the stool thin enough to drain easily. You will be
given a list of foods that are best to avoid (such as sweetcorn
/ mushrooms / skins / nuts) as these can block the catheter
and make it difficult to drain. You should peel your fruit and
vegetables.

Preparing for discharge

You will usually be able to go home 10-14 days after your
operation. The Medena catheter stays in place until you come
back to the clinic to see the surgeon and stoma care nurse (if
you are discharged less than two weeks after the operation). If
you are still an inpatient after two weeks, then we can take the
catheter out on the ward, and your stoma care nurse can teach
you how to catheterise the stoma.
Before you go home you must be able to flush the Medena
catheter twice daily with 20ml warm water and change the
gauze around the tube as necessary. If the Medena catheter
has been removed, you should have learnt how to do the
catheterisation procedure yourself and feel confidential doing so.

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Equipment to take home
The equipment we give you will vary depending on whether you
still have the Medena catheter in place. If you do, we send you
home with:
• 10 bladder syringes.
• 5 incontinence sheets – to be used in the early days to set
equipment on.
• Leg bags / night drainage bags – these can be washed and re-
used. If the stool becomes too thick to empty, the bags may
need to be thrown away.
• 2 rolls of “Sleek” or similar tape.
• 2 spare Medena catheters.
If you have had the Medena catheter removed before your
discharge, we will send you home with plenty of stoma caps (to
cover the continent Ileostomy), lubricating jelly and syringes and
make sure that you have learnt the catheterisation technique.
You will also be given the contact number for your local stoma
care nurse and district nurse. Your hospital stoma care nurse
will contact your local stoma care nurse and inform them of the
details of your operation before your discharge.

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Catheterisation of Koch pouch
You will return to the clinic approximately 2-4 weeks after the
operation to have the Medena catheter removed and learn how
to intubate / catheterise the stoma (unless the Medena catheter
was removed while you were still in hospital). You will need to
do this 2-4 times a day for life. (Williams 2002)
If you live at a distance, it is advisable to be prepared to stay all
day in Oxford. This will give you the opportunity to meet with
the stoma care nurse twice to make sure you are competent
in the catheterisation technique. We can usually complete the
training on the same day.

Removal of the “post-operative”

Medena catheter
(which should be carried out by the Stoma Care
Nurse or Surgeon):
1 Gently remove the tape/appliance securing the Medena
catheter.
2 Mark with a pen the entry point of the Medena catheter to
record the length it was inserted in theatre.
3 Flush catheter with 30mls warm tap water to allow ease of
removal.
4 Ensure any stitches securing the Medena catheter to the
stoma are cut.
5 Remove the catheter very gently.
6 Measure the insertion length (you will be told what this is).

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To catheterise Koch pouch
First, wash hands thoroughly.
Assemble equipment:
1 Incontinence pad (to place equipment on).
2 Medena catheter. (Mark on the new catheter the length at
which the operative catheter was inserted so that you do not
insert the new catheter beyond this point. This also serves to
give a sense of reassurance).
3 Lubricating jelly.
4 Jug or bowl to empty the pouch contents into.
5 “Bladder” syringe with 30mls warm tap water.
6 A cover for the stoma (required for use after the procedure –
some patients use a “one piece” or “two-piece” stoma cap
system).
Method
• Firstly, lubricate the Medena catheter well with the lubricating
jelly. The first time the new stoma is catheterised, it is
advisable for the stoma care nurse to examine the stoma and
the direction of the valve by gently inserting a gloved finger.
Gently insert the Medena catheter through the stoma as far as
the line marked by the stoma care nurse.
• Irrigate Medena catheter – gently insert 20-30mls warm tap
water into the pouch. Drain the contents of the Koch pouch
along with the water you have administered.
• Do not withdraw the contents of the pouch into the syringe.
– If the tube becomes blocked, it may be necessary to remove
and rinse the tube to unblock it and then re-insert.
– Do not insert more than 60ml water into the pouch without
draining it.

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• When the pouch contents have drained, gently remove the
catheter. If there is any difficulty/resistance in removing the
catheter, it may be necessary to gently flush with 10mls of
water as it is withdrawn.
• Apply pouch dressing (cap or gauze).
• Wash the equipment thoroughly with soapy water and allow
to air-dry if possible.
• N.B. After a month, the Medena catheter must be discarded
and a new one used, as cracks can occur in the tubing which
could traumatize the valve.

Schedule for when the Medena catheter is

first removed
1. Catheterise the pouch every 2 hours during the day and once
at night, for which an alarm clock will probably have to be set.
2. Each week, increase the intervals between the catheterisations
by one hour.
3. After a few months, most patients need to catheterise just
2-4 times in a 24 hour period (Williams 2002). Generally the
pouch should be washed out once a day with warm water of
drinking quality – so be careful when travelling abroad that
the water is fit for consumption.

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Medic Alert Bracelet
We strongly advise you to get a Medic Alert bracelet. This shows
that you have a Koch pouch in case of an emergency. It should
contain the following information:
• Internal pouch / Continent ileostomy / Koch pouch.
• Medena catheter to be inserted 4-6 hourly into pouch.
e.g. “Medic Alert”: MedicalAlert.org.uk
(NB The Medical Alert Foundation can provide a bracelet free of
charge for those on low incomes). There is a yearly fee to belong
to the Foundation.

Follow up
You will be followed up:
1. Approximately 2 weeks after your operation and then at
6 months.
2. Yearly out-patient check with surgeon or nurse-led pouch
clinic.
3. Annual blood tests for:
– Full blood count
– Urea and Electrolytes
– Liver Function tests
– Ferritin
– Vitamin B12
4. If you had your Koch pouch formed because you had a
diagnosis of Ulcerative Colitis, a pouchoscopy (look into the
pouch with a scope) will need to be performed every 3 years
(once you have had Ulcerative Colitis for ten years or more).
Any signs of dysplasia (abnormalities in the pouch wall) will
indicate the need for biopsies to be carried out.
You may contact the surgeon or stoma care nurse at any time
between your check-ups if you have any questions or concerns.

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Obtaining supplies once home
All the equipment for the Koch pouch is available on prescription
from your doctor. This can then be obtained from your chemist
or a delivery service.

Pregnancy and childbirth

A pregnant mother-to-be may find it slightly more difficult to
catheterise the continent ileostomy during the third trimester,
depending on the size of the baby and its position. If this
happens it may be necessary to leave the catheter in on free
drainage during the third trimester. In this case we can advise
you on securing the catheter if this necessary.

What if I get problems once I am at home?

Because the operation is performed rarely in the United
Kingdom, you may need to return to Oxford depending on
the nature of the problem. Contact your GP or local hospital
for advice – they may need to refer you back to a colorectal
consultant/ specialist registrar in Oxford.
Tel: (01865) 741166
Ask switchboard to bleep the Colorectal Specialist Registrar on
call.
During office hours Mon- Fri (except bank holidays) you
can also reach an Oxford stoma care nurse specialist by
bleep on this number: 1865 741166 Ask for bleep 1765)

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References:
Cleveland Clinic Health Information Pack – For Patients and the
Community – Continent Ileostomy – Home Going Instructions
(no date).
Hull, T.L., Erwin-Toth, P (1996)
Pouch Procedure and continent Ostomies. “Overview and
Controversies”. Journal of WOCN. Vol 23, No. 3, pp.156-165
Medic Alert Bracelet http://www.medicalalert.org.uk.
Perrin, A. 2008 Nurse-Led Pouch clinic protocol.
Williams J (2002) The Essentials of Pouch Care Nursing. London:
Whurr.
With grateful thanks to Paula Erwin-Toth, Director WOC/ET
Nursing Education, The Cleveland Clinic Foundation, USA.

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If you need an interpreter or need a document in another
language, large print, Braille or audio version, please call
01865 221473 or email PALSJR@orh.nhs.uk

Fran Woodhouse, Clinical Nurse Specialist, Stoma/Colorectal Nursing

Version 1, September 2010
Review September 2013
Oxford Radcliffe Hospitals NHS Trust
Oxford OX3 9DU
www.oxfordradcliffe.nhs.uk

OMI 2343